Adolescent Contraception

Introduction

The Centers for Disease Control and Prevention's 2005 Youth Risk Behavior Surveillance Summary reported 34.3% of all students being currently sexually active. 850,000 adolescent girls become pregnant each year. It is important to note that 35% of teenagers do not use contraception during their first sexual encounter. 20% of teenage pregnancies occur within the first month of beginning sexual activity and 50% within 6 months. Follow-up data from 2010 showed that 18.3% of babies born to teenagers were repeat births. It is thus essential to initiate discussions about contraception prior to the beginning of sexual activity.

Talks with the adolescent must be both private and confidential. The overall goals of discussing the various methods of contraception with the adolescent are to prevent sexually transmitted diseases (STDs), prevent unintended pregnancies, and promote sexual education and healthy choices. There are serious consequences when an adolescent is not adequately informed about contraception methods. They may feel embarrassed about asking a physician for guidance on contraception or have fear that their parents will find out, feel they are invincible, and lack the knowledge of how to get access to care.

Methods of Contraception

Abstinence

Abstinence education focuses on the delay of initiation of adolescent sexual activity until marriage or adulthood.

Pros

Cons

100% effective method of birth control and prevention of STDs

No data on whether abstinence education reduces pregnancy or STD risk

Many adolescents who intend on being abstinent fail and have sex

Male Condoms

The male condom serves as a mechanical barrier method of contraception.

Pros

Cons

Latex condoms significantly reduce the transmission of some STDs

Should be used by all sexually active adolescents regardless of additional method of contraception

Involves males in the responsibility of contraception

Easy accessibility – available to minors, use without prescription, low cost, easy to transport

Can be coated with nonoxynol-9, a spermicidal product

Failure rate at the end of first-year use is 3% for perfect use and 14% for typical use

Polyurethane condoms can be used for those with a latex allergy, but they are less efficacious

Nonoxynol-9 use increases risk of genital ulceration and irritation thus increasing the likelihood of STD transmission

Adolescents may not use condoms every time they have sex (54% use by females and 71% use by males at most recent intercourse)

Female Condoms

The female condom also works by a barrier method of contraception. Its efficacy is similar to other barrier methods such as the diaphragm and cervical cap.

Pros

Cons

Helps protect against STDs

Very useful for females with male partners who do not want to use a condom

Can be inserted 8 hours prior to having sex

Can be used with spermicide

Failure rate of 0.8% with perfect use and 12%-15% with typical use

Adolescents have concerns about difficulty of insertion and appearance and noisiness of the device

Male condoms are cheaper and have higher efficacy rates of preventing pregnancy and STDs

Diaphragm and Cervical Cap

These are barrier methods which have higher efficacy when used with spermicide. The diaphragm is a flexible latex cup that is inserted into the vagina and must remain there for 6 hours after having sex. Cervical caps are latex or silicone cups that have a firm rim that suctions to the cervix preventing sperm from entering the uterus for up to 48 hours.

Pros

Cons

Failure rate of diaphragm with perfect use is 6% and 20% with typical use

Failure rate of cervical cap is 26% with perfect use and 40% with typical use

Require prescription and doctor's visit for fitting

Increased incidence of urinary tract infection

Does not prevent transmission of STDs

Requires some skill for use

Unpopular with teenagers

Vaginal Spermicides

Vaginal spermicides are applied intravaginally and serve as a chemical barrier method of contraception. They come as a gel, foam, suppository, or film. Nonoxynol-9 is the chemical compound that kills the sperm.

Pros

Cons

Very effective for adolescents when used in conjunction with condoms – prevents pregnancies, decreases risk of STDs, available without prescription, cheap

Women should not use nonoxynol-9 alone for STD and HIV protection – they may have an even higher rate of transmission when compared to lubricant alone

Not advocated as a contraception method when used alone

Oral Contraceptives (OCPs)

There are currently three formulations of OCPs including the fixed-dose in which each tablet contains the same dose of estrogen and progestin, the phasic dose which contain varying doses of estrogen and progestin, and the minipill which only contains progestin. OCPs are the most popular method of prescribed contraceptive among adolescents. Absolute contraindications include history of DVT, CVA, known Factor V Leiden mutation or other thrombophilic risk factors.

Injectable Hormonal Contraception

A long-acting progestin-only formulation, depot medroxyprogesterone acetate (DMPA), can be injected every 12 weeks as a single 150-mg intramuscular dose to serve as an effective method of contraception.

Pros

Cons

Highly effective in preventing pregnancy (pregnancy rate in first year of use is 0.3%)

Convenient and less dependent on compliance vs. the pill

Lack of estrogen-related adverse effects

Protection against endometrial cancer and iron-deficiency anemia

Menstrual cycle irregularities

High discontinuation rate amongst adolescents (33% choosing to discontinue after first shot)

Progestin Implants

Norplant-2 and Implanon are levonorgestrel implants that are inserted subcutaneously into the upper arm in the doctor's office. It is a highly effective progestin-only contraceptive that works for up to 5 years.

Pros

Cons

Good for adolescents who want an extended length of protection

Convenient – do not need to remember to take a pill every day or bring a barrier

High initial cost

Adverse effects include breakthrough bleeding and headaches

Some medications may decrease its efficacy

Difficult to remove

Does not prevent transmission of STDs

NuvaRing

NuvaRing is a round and flexible vaginal ring that is inserted in the vagina and stays in place for three weeks, subsequently removed for one week to induce menstruation, and inserted again. The ring is made of silicone and releases estrogen and progestin.

Ortho Evra

Orthro Evra is a transdermal adhesive skin path that contains norelgestromin and ethinyl estradiol. It can be applied to the abdomen, upper torso, upper outer arm or buttocks weekly. One patch lasts for one week and three patches are used for three weeks in a row followed by one week without the patch to induce withdrawal bleeding.

Pros

Cons

Same efficacy as OCPs

Higher compliance than with OCPs

Adolescent girls are more likely to dislodge the patch and experience irritation and hyperpigmentation than adult women

2005 FDA warning: patch may be associated with increased estrogen exposure, though this may be based on difference in pharmacokinetic profiles of various patients.

Intrauterine Devices (IUDs)

IUDs are inserted into the uterus where they release hormones, ions or enzymes that prevent sperm from fertilizing the ova or prevent implantation. Mirena releases the progestin levonorgestrel and is effective for 5 years and ParaGard releases copper that kills or immobilizes sperm and is effective for 10 years. Absolute contraindications include a past history or continuing risk for ectopic pregnancy.

Pros

Cons

Safe and effective method of contraception (fail rate <1%)

Does not affect fertility in the absence of infection

Useful for adolescents with severe menorrhagia and dysmenorrhea, as amenorrhea can occur in 1 year in 20-50% of patients.

Does not prevent transmission of STDs

Usually nor recommended for nullparous women

Withdrawal

The withdrawal method is when the male partner withdraws his penis from the vagina before ejaculation. It is very commonly used by adolescents.

Pros

Cons

Failure rate of 19% within the first year

Does not prevent transmission of STDs

Periodic Abstinence Methods

This requires the female partner to have a strong awareness of her menstrual cycle and reproductive fertility. In this method, the partners abstain from having sex on the days when sex is most likely to result in pregnancy.

Pros

Cons

Failure rate of >25% in the first year

Particularly ineffective for adolescents because ovulation may not be predictable in the first few years after menarche

Does not prevent transmission of STDs

Emergency Contraception

Emergency contraception can be administered either by ingesting oral hormones or inserting a copper-releasing IUD. An IUD can be inserted to prevent pregnancy for up to 5 days after having unprotected sex. The oral preparation of the progestin-only regimen, known as Plan B, is the much more popular method of emergency contraception. The two pills in Plan B should be taken within 72 hours of having unprotected sex. Absolute contraindications include known pregnancy due to its lack of efficacy in such an instance, but a pregnancy test should be administered only if pregnancy is suspected.

On a policy level, providers should advocate for increased non-prescription access to emergency contraception for teenagers to reduce cost-barriers.